A Case of Fungal Keratitis Secondary to Cylindrocarpon Destructans

doi:10.4236/ojoph.2012.22007

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Open Journal of Ophthalmology, 2012, 2, 31-33

http://dx.doi.org/10.4236/ojoph.2012.22007 Published Online May 2012 (http://www.SciRP.org/journal/ojoph) 31

A Case of Fungal Keratitis Secondary to Cylindrocarpon

Destructans*

Rajen Tailor1#, Ibrahim Elaraoud2, Mike Quinlan3

1Birmingham and Midlands Eye Centre, City Hospital, Birmingham, England; 2University Hospitals of Coventry and Warwick,

Coventry, England; 3Russells Hall Hospital, Dudley, England.

Email: #[email protected]

Received December 23rd, 2011; revised January 28th, 2012; accepted February 18th, 2012

ABSTRACT

Purpose: To report the first human case of fungal keratitis caused by Cylindrocarpon destructans and to highlight the

issues with the use of topical steroids, the duration of antifu ngal treatment and the potential role of topical ciclosporin.

Methods: A patient presented following being inj ured in the left eye by a fuchsia plant. Data was collected by slit lamp

examination and review of the case notes and microbiology reports. Results: No organisms were cultured from a cor-

neal scrape however cultures from a corneal biopsy identified cylindro carpon species morphologically resembling Cyl-

indrocarpon destructans. The patient responded well to topical amphotericin and clotrimazole and oral voriconazole but,

developed a corneal perforation, which required an urgent tectonic penetrating keratoplasty (PKP). Despite being on

topical dexamethasone and natamycin, the patient presented two months post-operatively with a corneal epithelial de-

fect and a large hypopyon. Subsequently, the patient developed a deep corneal infiltrate and corneal vascularisation

with a persistent epithelial defect. Conclusion: This is the first reported case of keratitis caused by Cylindrocarpon de-

structans. The case highlights: the contentious issues in the use of topical steroids following PKP and the duration of

antifungal treatment both in primary infection and following PKP. Furthermore, the case accentuates a potential role for

ciclosporin as an alternative to steroids following PKP.

Keywords: Cylindrocarpon Destructans; Ciclosporin; Fungal Keratitis; Penetrating Keratoplasty; Topical Steroids

1. Case

A 74-year-old man sustained an accidental injury to the

left eye (OS) by a fuchsia plant. The following day he

attended the local emergency department complaining of

redness and soreness. His visual acuity in the left eye was

noted to be 6/9 and a large corneal abrasion was identi-

fied. He was commenced on chloramphenicol ointment

four times a day and referred to the eye clinic.

On review in the eye clinic, the patient complained of

severe eye pain. His visual acuity (VA) was 6/30 OS and

slit lamp biomicroscopy examination showed a large

epithelial defect, 2+ of anterior chamber white cells and

iris hemorrhages. He was commenced on guttae (G) ce-

furoxime 5% and ofloxacin 0.3% hourly. The patients

symptoms gradually improved and on day seven of topi-

cal antibiotic treatment, prednisolone 0.5% QDS was

added. Three days later, the patient presented with wors-

ening of his symptoms associated with a 3.6 mm hemor-

rhagic hypopyon (Figure 1). The patient was admitted to

the eye ward where all treatment was stopped for 24

hours and a corneal scrape from the edge of the epithelial

defect was performed. The culture showed no growth.

The patient was commenced on oral fluconazole 200 mg

BD, G. penicillin, G. gentamicin and G clotrimazole one

*Disclaimer: No proprietary interest. No financial support was re-

ceived.

#Corresponding author. Figure 1. Left eye hemorrhagic hypopyon on presentation.

A Case of Fungal Keratitis Secondary to Cylindrocarpon Destructans

hourly day and night. As the corneal signs improved,

with a reduction in the epithelial defect and hypopyon,

the patient was discharged. Unfortunately, on follow up

in clinic, there was an increase in the hypopyon and

epithelial defect with an anterior stromal infiltrate. The

patient was readmitted and a corneal biopsy and anterior

chamber washout was performed. Histology showed an

acute inflammatory exudate permeating the corneal

stroma and multiple septate and br anching fung al hyphae

with spores.

Culture identified cylindrocarpon species morpho-

logically resembling Cylindrocarpon destructans (my-

cology reference lab Bristol, UK).

The patients treatment was changed to voriconazole

200 mg BD, G. amphotericin and G. clotrimazole one

hourly. This resulted in a reduction in symptoms, hy-

popyon and infiltrate and so, the patient was discharged

home. However, three day following discharge, VA was

hand movements and corneal perforation with a flat ante-

rior chamber was noted. An urgent tectonic penetrating

keratoplasty (PKP) was performed. Postoperative treat-

ment included G. chloramphenicol 2 hourly, G. Natamy-

cin six times a day, G. Atropine OD, G. Dexemathasone

preservative free QDS, G. Ciprofloxacin TDS and oral

voriconazole 200 mg BD.

Five week following the PKP, the graft remained clear

and all treatment was stopped except dexamethasone,

chloramphenicol and natamycin QDS. Two month fol-

lowing the PKP, the patient presented to clinic com-

plaining of a white spot on the left eye. Examination re-

vealed a 1.2 mm × 1.2 mm epithelial defect with a 5.5

mm hypopyon (Figure 2). Initially, the chloramphenicol

and dexamethasone were reduced to TDS, natamycin

was increased to 2 hourly and the patient was recom-

menced on oral voriconazole 200 mg BD. Three days

later, the hypopyon had reduced but a deep stromal infil-

trate was noted at the junction of the graft and host.

Topical dexamethasone was stopped and in addition to

the above treatment, oral ciprof loxacin and flucloxacillin

were added. One week later, the stromal infiltrate had

increased. We therefore performed an anterior chamber

washout during which we noted thick exudate adherent

to the corneal endothelium and iris with significant pe-

ripheral synechiae. Intracameral amphoteracin and van-

comycin were administered. Post operatively, the pa-

tients treatment was simplified to oral Voriconazole 200

mg BD and G. amphoteracin 0.15% two hourly. On ini-

tial follow-up, the stromal infiltrate had reduced.

Two week following treatment the infiltrate had fur-

ther reduced, however, there was superior superficial

vascularisation of the corneal graft, a persistent epithelial

defect, and a descemetocoele (siedel negative) (Figure

3).

The case was discussed at our regional corneal grand

Figure 2. Left eye two month following PKP. Hypopyon

shown.

Figure 3. Left eye superficial vascularisation, epithelial de-

fect and a descemet oc oele.

round and the consensus was that the patient is likely to

have significant anterior segment scarring with a poor

prognosis with any further surgical intervention.

On six month follow up, the epithelial defect had

healed and all treatment was stopped. The patient has not

had any further recurrences.

2. Discussion

We present the first reported case of Cylindrocarpon de-

structans causing keratitis in humans. Furthermore, the

case highlights the dilemma of the duration of antifungal

treatment both in the primary infection and following

penetrating keratoplasty (PKP) and the risks of using of

topical steroids following PKP.

Cylindrocarpon destructans is a soil fungus often asso-

ciated with plant roots. They may be saprobes or faculta-

tive plant pathogens.

To date there have been several reported cases of Cyl-

A Case of Fungal Keratitis Secondary to Cylindrocarpon Destructans

indrocarpon lichen icola causing keratitis in humans [1-4]

and a single case series of Cylindrocarpon destructans

causing keratitis in horses [5]. However, the only re-

ported case of Cylindrocarpon destructans causing dis-

ease in humans is that of a chronic foot abscess in a 39

year old male [6].

There is very little clinical evidence on the use or tim-

ing of use of topical steroids in the medical management

of PKP in patients with fungal keratitis. The clinical di-

lemma with the post-operative use of topical steroids is

reduction of inflammation & prevention of rejection

versus the risk of recurrence of fungal keratitis.

In a series of 54 patients with fungal keratitis who un-

derwent PKP [7], patients were divided into 2 post-op-

erative treatment arms. Group one received topical flu-

conazole (doflucan) and topical ciclosporin and group

two received only topical fluconazole. The authors found

that there was no increase in the recurrence rate of fungal

keratitis in-group one compared to two and, the eyes

were less inflamed in group one. Hence, there may be a

role for the use of topical ciclosporin post PKP in this

group of patients.

With regards to the use of topical steroids following

PKP, in a large series of 358 patients with fungal keratitis

[8], systemic and topical steroids (specific drug names

were not stated) as well as topical 1% ciclosporin were

given 2 weeks after PKP if recurrence did not occur. The

authors choose 2 weeks as all the recurrences (7.4% of

PKP performed) occurred within 2 weeks post opera-

tively.

There is very little information in the literature on the

duration of anti-fungal treatment. In the above mentioned

series [8], both topical (0.25% amphotericin and 5% na-

tamycin) and an oral fluconazole were used. However,

only the duration of topical antifungal treatment was

stated (five days to one month (mean eleven days)). In

those patients that required emergency PKP (108% -

32%), during the procedure, the hypopyon & fibrinous

membrane were carefully removed and the anterior

chamber was irrigated with fluconazole 0.2%. Post

operatively, subconjunctival fluconazole was given for 3

days, oral fluconazole was given for 21 days, fluconazole

or amphotericin B ointment was administered at night

and fluconazole 1% drops QID were given during the

day. All treatment was tapered and stopped by day 20 - 30

post-operatively. Our case is unusual in that recurrence

occurred two months following PKP.

In conclusion, this is the first reported case of Cylin-

drocarpon destructans causing keratitis in humans. Fur-

thermore, the case highlights the contentious issues of th e

use of topical steroids following PKP, the potential role

of topical ciclosporin and the duration of antifungal

treatment both in primary infection and following PKP.

Antifungal treatment may need to be continued for sev-

eral months, particularly following PKP.

REFERENCES

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